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4/21/21njm Intrauterine Fetal Demise Labor Management

Background

Mid-trimester induction may be indicated for intrauterine fetal demise (IUFD), life- threatening maternal complications, or lethal fetal anomalies. At term, induction of labor in women with a prior cesarean, and especially those whose labors are induced with prostaglandin preparations, have been associated with a greater risk of . However, the risk of prostaglandins in women with a scarred uterus does not seem to be similar in the second trimester.

Both misoprostol and dinoprostone have been studied in such women, and, because of low cost and a more favorable side effect profile, misoprostol seems to be the optimal agent. While oxytocin is an option in the second trimester, larger doses and longer induction time may be necessary. Comparisons of misoprostol and oxytocin document their comparable safety and efficacy at this gestational age in women without prior uterine surgery.

If 414 women with a history of cesarean delivery were given misoprostol for second- trimester , one would experience uterine rupture. Advanced gestational age, high gravidity (≥3 ) or uterine anomalies may also increase risk of rupture.

Management

1. Women who are candidates for cervical ripening will be admitted to L&D for induction with the agents below. 2. Women will be excluded from this guideline if they have an overdistended uterus (multiple gestation, ); at high risk of uterine rupture (a prior classical or T-shaped uterine incision, or extensive transfundal uterine surgery [e. g., myomectomy]); or have a known sensitivity to misoprostol. 3. Maternal vital signs and cervical examination will be documented, and intravenous access will be established. 4. Misoprostol tablets (Cytotec) will be inserted high in the posterior vaginal fornix without the use of lubricant or taken orally. 5. Patients will remain recumbent for 30 to 60 minutes following placement of the tablets, but thereafter may ambulate as desired and take oral fluids ad lib. Uterine monitoring is optional. (This dose of misoprostol will commonly result in uterine tachysystole, but without the same implications as at term with a viable pregnancy.) Maternal vital signs should be recorded as per routine. 6. Medical regimens:

< 24 weeks all women 400 mcg PV q4 hours for 5 doses Pretreatment with mifepristone 200mg PO 24 hrs prior, if possible

No previous cesarean/uterine surgery

24 0/7 - 27+6 weeks 400mcg PV or PO q4hrs 2

28 0/7 - 31+6 weeks 50 cg PV miso x1 then wait 4 hours. 100 mcg vaginal miso q4hrs x 5 doses

>32 0/7 weeks Follow oral titrated miso guideline for cervical ripening

Previous cesarean / uterine surgery:

24 0/7 - 27+6 200 mcg miso PV q4hrs

28 0/7 - 40+ Cervical ripening balloon and oxytocin

7. Delivery should be expected within 24 hours in up to 90% of patients. The remaining women should be expected to deliver within 36-48 hours without addition of a second agent. Amniotomy may be performed at any time at the discretion of the provider. 8. If for whatever reason the provider desires to change the induction agent to oxytocin, an interval of 4 hours since the last misoprostol dose should be allowed. Misoprostol and oxytocin should not be used concomitantly, nor should misoprostol and dinoprostone (Cervidil, Prepidil) be used together. 9. Any type of maternal analgesia (intravenous narcotic or epidural) is appropriate. 10. Uterine rupture should be suspected in a woman with severe or persistent abdominal pain and signs of intraabdominal bleeding. Prompt laparotomy is indicated in patients with a presumptive diagnosis of uterine rupture. 11. Delivery of the will commonly occur precipitously. 12. The placenta is often delivered within 60 minutes following delivery of the fetus and expectant management is usually appropriate unless excessive maternal hemorrhage occurs prior to that time. If two hours have passed and the placenta has not delivered, an infusion of oxytocin 30 units in 500 mL of NS is indicated. If the placenta is not delivered after infusion of oxytocin or the woman starts bleeding excessively, manual or surgical removal of the placenta may be required. Oxytocin may be administered following delivery of the placenta at the discretion of the provider.

REFERENCES

1. Misoprostol for postabortion care. ACOG Committee Opinion No. 427. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:465-8. (Accessed 4/21/21) 2. Second-trimester abortion. Practice Bulletin No. 135. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:1394–1406. (Re- affirmed 2019) (Accessed 4/21/21) 3. Schreiber CA, Creinin MD, Atrio J, Sonalkar S, Ratcliffe SJ, Barnhart KT. Mifepristone Pretreatment for the Medical Management of Early Pregnancy Loss. N Engl J Med. 2018 Jun 7;378(23):2161-2170

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4. Dickinson JE, et al. Misoprostol for second-trimester pregnancy termination in women with a prior cesarean delivery. Obstet Gynecol 2005; 105:353-6. 5. Daskalakis GJ, et al. Misoprostol for second trimester pregnancy termination in women with prior caesarean section. BJOG 2005; 112:97-9. 6. Pongsatha S, et al. Misoprostol for second-trimester termination of pregnancies with prior low transverse cesarean section. Int J Gynaecol Obstet 2003; 80:61-2. 7. Rouzi AA. Second-trimester pregnancy termination with misoprostol in women with previous cesarean sections. Int J Gynaecol Obstet 2003; 83:317-8. 8. Herabutya Y, et al. Induction of labor with vaginal misoprostol for second- trimester termination of pregnancy in the scarred uterus. Int J Gynaecol Obstet 2003; 83:293-7. 9. Ramsey PS, et al. Vaginal misoprostol versus concentrated oxytocin and vaginal PGE2 for second-trimester labor induction. Obstet Gynecol 2004; 104:138-45. 10. Goyal V Uterine rupture in second-trimester misoprostol-induced abortion after cesarean delivery: a systematic review. Obstet Gynecol. 2009 May;113(5):1117- 23. 11. Ho, PC, Blumenthal, PD, Gemzell-Danielsson, K, et al. Misoprostol for the termination of pregnancy with a live fetus at 13 to 26 weeks. Int J Gynaecol Obstet 2007; 99 Suppl 2:S178.

Revised 4/21/21 njm Reviewed 10/16/19 njm Reviewed 12/9/17 njm Revised 11/14/15 njm Reviewed 1/15/13 njm Revised 11/29/10 njm Written 4/5/07 gg